critical“There were no individual capacity assessments or best interest decisions in place for this person. This placed this person at risk of not receiving care and treatment they had consented to or in their best interest.”
critical“The nominated individual was not aware of their responsibilities in relation to the MCA...placed people at risk of being deprived of their liberty without authorisation.”
governance
2 findings
critical“Quality checks and audits were inconsistently completed in the service. There were no audits in place to identify that people's care was not being delivered in line with MCA.”
critical“The provider had failed to establish systems to assess, monitor and improve the quality and safety of the service provided. This placed people at risk of harm.”
medication management
2 findings
moderate“Staff were not currently signing the MAR, they were putting an 'x' to show administration. The medicines audit had not identified where staff were not signing the MAR.”
critical“Systems had not been established to ensure the safe administration and management of medicines. Staff had not received training to ensure they were safe to support people with medicines.”
staff competency
2 findings
moderate“Although staff had received training since the last inspection, there was a lack of understanding around the Act and from the registered manager and provider around their responsibilities.”
critical“There was no record of competency assessments ever being carried out. This placed people at risk of harm.”
record keeping
2 findings
minor“Risk assessments and care plans were now in place when needed... Some of these lacked detail however the registered manager was aware of this and working to improve these.”
moderate“Staff had not been trained sufficiently in the recording of people's care and support. We found daily notes were extremely limited and contained little information.”
safeguarding
1 finding
critical“They had failed to notify CQC of the concerns as required by law. The nominated individual advised they were not aware of their duty to notify us of safeguarding incidents.”
staff training
1 finding
critical“There was no record of staff having received an induction and the provider relied on the skills and knowledge staff had acquired in other employment.”
care planning
1 finding
critical“Care plans failed to identified people's individual preferences and were generic in nature. People's needs had not been fully assessed.”
leadership
1 finding
critical“The registered manager had only been available to work at the service for approximately 2 weeks of each month...lack of oversight and governance systems were detrimental to the care people received.”
person centred care
1 finding
moderate“The provider failed to carry out full assessments of need for people and failed to review people's care to ensure it still met their needs.”
end of life care
1 finding
moderate“Guidance about how they should be specifically supported in relation to their end of life wishes had not been considered.”
cultural competency
1 finding
minor“There was a lack of information available for staff about people's individual needs in relation to race, religion or sexual orientation.”
communication with families
1 finding
moderate“Only one person was aware of who the nominated individual was. No-one who spoke with us knew the registered manager.”